Piriformis Syndrome Case Study
What are my first thoughts about this case study?
• When I first read about Carla’s presentation into the clinic, it sounded like it was piriformis syndrome. Although rarely recognized, piriformis syndrome appears to be a common cause of buttock and leg pain as a result of injury to the piriformis muscle. Symptoms are aggravated by prolonged hip flexion, adduction, and internal rotation, in the absence of low back or hip findings (Barton, 1991). Tonley et al. (2010) stated piriformis syndrome often evolves as intermittent and inconsistent and can present symptoms off and on throughout prolonged periods of time. Patients often report pain is insidious and deny any trauma that contributed to current symptoms. Patients also often state prolonged history of deep right buttock pain that radiates to the posterior thigh when piriformis syndrome is present (Tonley et al., 2010).
• Passive motion assessment of the hip joint in patients with piriformis syndrome often reveals normal ranges of motion for hip flexion, internal rotation, and external rotation without reproduction of symptoms (Tonley et al., 2010). Manual muscle testing above revealed slight weakness in the hamstrings which may be related to lower-crossed syndrome (LCS). In LCS, tightness of the thoracolumbar extensors on the …show more content…
dorsal side appears along with contralateral tightness of the iliopsoas and/or rectus femoris on the ventral side (making the first part of the “X or crossing of muscular tightness”), causing potential anterior rotation of the pelvis (Page, Frank, & Larnder, 2010). To expand upon this, at stated by Tonley et al. (2010), a common assumption guiding physical therapy intervention for piriformis syndrome is that the piriformis is shortened or in spasm, creating compression of the sciatic nerve. However, there is an alternate theory in which the piriformis muscle may be functioning in an elongated position or subjected to high eccentric loads during functional activities secondary to weak agonist muscles and the adopted anterior rotation of the pelvis also causing hamstring weakness as it is potentially elongated (Tonley et al., 2010; George, 2011). However, sciatic pain symptoms can be remarkably similar no matter what the source of pain truly is. Usually, there is some degree of actual pain in the buttocks, legs, or feet and can be cancer related (“Sciatica from Cancer,” 2015). Patients with cancer can endure all of the usual causes of sciatica, including spinal and nonspinal structural explanations. Sometimes, the tumor grows directly on a nerve structure (“Sciatica from Cancer,” 2015).
What is a spinal MRI going to look for and what will show up on this imaging?
• Magnetic Resonance Imaging was developed in the 1980’s and has revolutionized the ability to see normal and abnormal spinal structures and help diagnose back pain and possible disruptions in disc lesions, spinal cord compression, and many other possible diagnosis (Shalen, 2012). MRIs represent a very sensitive and accurate assessment of spinal anatomy, it cannot however distinguish between painful and non-painful structures in the spine. In fact, a patient may have severe back pain and an MRI that shows a relatively normal-looking spine, or conversely may have no back pain but the MRI reveals a lot of anatomical problems. Thus, the findings on MRI scans do not constitute a diagnosis (Shalen, 2012). MRIs can reveal spinal alignment, disc height and hydration, vertebral body configuration, intervertebral disc (normal, bulging, herniated, dehydrated, or degenerated), spinal canal size, nerves, abnormalities, and spinal cord appearance (Shalen, 2012).
Why was there a decrease sensation to light touch and sharp/dull?
• Sensation to touch and light/dull in the corresponding areas the patient presented with indicated either an S1 nerve root problem or potential peripheral nerve entrapment/compression (tibial nerve with medial and lateral plantar nerve distribution to medial/lateral portions of the foot respectively). Since this patient complained of low back pain/posterior hip pain on the right, and pain radiating down the posterolateral aspect of her leg and heel that was exacerbated on the straight leg raise, sounds like a potential sciatic nerve problem or disc involvement. However, what we don’t know from the description of this case is at what angle during the straight leg raise these symptoms came on. Was it at 0-35o where the sciatic nerve is slack and is taken up during the entirety of that range with no dural movement? Or was it during 35-70o of the range where the sciatic roots tense over the intravertebral disc during this range? Then if it is over 70o the sciatic nerve is no longer stretched and pain would indicate joint involvement (learned throughout experience in physical therapy program). Further information about this would be nice to know, however, it may still sound like there is more than one problem here because she has increased pain with palpation in the gluteal region which makes sense, however, she has it on anterior palpation just below her ASIS, which sounds like possible bone involvement such as a type of bone cancer or something other than a musculoskeletal problem.
Why is Indocin prescribed/what is it used for? What are some common side effects from taking Indocin?
• Indocin is a nonsteroidal anti-inflammatory drug (NSAID). Indocin (indomethacin) works by reducing hormones that cause inflammation and pain in the body (“Drugs”, 2016). Indomethacin is used to treat moderate to severe osteoarthritis, rheumatoid arthritis, gouty arthritis, or ankylosing spondylitis. It is also used to treat shoulder pain caused by bursitis or tendonitis. Indomethacin can increase your risk of fatal heart attack or stroke, especially if long term use or taking high doses, or if you have heart disease. This may also cause stomach or intestinal bleeding, which can be fatal (“Drugs”, 2016). This case has not given any specifics up until this point as to why the patient is taking Indocin, however, based on the information up until this point, it would make the most sense that this patient is taking this medication for anti-inflammatory purposes to reduce the cause of inflammation and pain the body she is experiencing.
What is the most logical reason for bladder urgency in this patient?
• This patient also indicated that over the past 2 years, she has experienced increased bladder urgency for which she has not sought medical attention. She also was diagnosed with irritable bowel syndrome about 10 months ago. Upon further research, it appears that bladder symptoms and irritable bowel syndrome (IBS) actually have a surprising overlap and that some researchers have estimated that urinary symptoms may be experienced as many as 50 percent of people who have IBS (Bolen, 2016). These symptoms include: frequent urination, incomplete emptying of the bladder, nocturia, urinary urgency. If this patient is indeed having pelvic pain which may seem like back pain, there are multiple organ systems in the pelvis, there is the gastrointestinal system (intestines), gynecologic system (ovaries and uterus), genitourinary system (bladder and kidneys) and all these three systems exist side by side in the pelvis so if pelvic pain, it can be one of the three (Bolen, 2016). The most common comes from gas and can be quick/sharp pain. However, this is a persistent pain or comes on and off (cyclic), it may be one of these systems above and should be screened (Bolen, 2016). The problem could also be Interstitial cystitis (IC), also known as painful bladder syndrome, on the surface looks like the urological counterpart of irritable bowel syndrome (IBS) (Bolen, 2016). Following the clinical presentations given in the case study, I do not think the patient has any of the following diagnoses that I have addressed in this objective; however, it was relevant information to consider given her history.
What are some additional differential diagnoses?
• Upon further research about Irritable Bowel Syndrome, I came across colorectal cancer. I found that colorectal cancer might not cause symptoms right away, but if it does, it may cause a change in bowel habits, such as diarrhea, constipation, or narrowing of the stool, that lasts for more than a few days which may be related to her bowel/bladder urgency (American Cancer Society, 2015). It may also lead to cramping or abdominal pain, weakness/fatigue, and unintended weight loss. This type of cancer can often bleed into the digestive tract. One thing we don’t know about in this case is if her stool looks normal. Over time, the blood loss can build up and can lead to low red blood cell counts (anemia) (American Cancer Society, 2015). A great thing to know in this case is what her numbers on a blood test look like and if her red blood cell count is low. This is one thing that I would really want to see. However, in early stages of the disease, colorectal cancer symptoms may be minimal, or not present at all. As the disease progresses, symptoms may increase in quantity and degree of severity. Because colorectal cancer symptoms often do not present themselves until the disease has progressed past the initial stage, regular screening is often recommended, and should be part of a continued health plan for anyone over 50 (Fisher & Daniels, 2014). It is not clear if this patient has a family history of colorectal cancer because if so, it is recommended that if you are under 50, which this patient is, individuals should talk with their doctor about when screening regularly should begin (Fisher & Daniels, 2014).
• Another interesting point is that colorectal cancer is broken down into two general categories: local and systemic. Local symptoms are those that have a direct effect on the colon or rectum. If symptoms are experienced for an extended period of time, it is important that a healthcare professional is contacted. The symptoms of a local colorectal cancer are more of the symptoms described previously. Systemic colorectal cancer symptoms are those that affect the entire body. If these symptoms are experienced for any lengths of time, or even a couple of days it is important that a healthcare professional is contacted. This would include unexplained weight loss, unexplained loss of appetite, nausea or vomiting, anemia, jaundice, weakness or fatigue (American Cancer Society, 2015). None of these are mentioned in this case study other than weakness/fatigue.
Could any type of neurological or autoimmune disease cause these types of clinical presentations?
• This patient also fits the presentation for multiple sclerosis (MS), although I do not think this is the patient’s current diagnosis. These individuals tend to have their first symptoms between ages 20 and 40 (Wootla, Eriguchi, & Rodriquez, 2012). The patient in this case is 35 years old and matches this description. Also, with MS, symptoms tend to get better, but then come back. Some symptoms may come and go, while others linger. This again, is another common theme we are seeing with this patient as she sometimes goes a few weeks without pain, and then the pain comes back. An important early symptom of MS to note is clumsiness or lack of coordination which is something we may be seeing from this patient as she has no limitations in ROM, not many limitations as far as weakness, however, demonstrates an antalgic gait pattern along with the inability to ambulate without crutches.
Could the cause of the patient’s current symptoms be present due to some type of cancerous or precancerous tumor?
• Tumors involving the sacrum could also be a more likely cause of this patient’s presentation as this type of problem can compress or invade neighboring structures (Mavrogenis, Patapis, Kostopanagiotou, & Papagelopoulos, 2009). Sacral tumors remain silent for a long time and the most common initial symptom of a sacral tumor is local pain due to its mass effect and compression. Occasionally, such as this case, lower sacral tumors can grow large enough for their anterior portion to be palpated during an examination. Lateral extension of sacral tumors across the sacroiliac joints cause local pain at the joint. According to Mavrogenis, Patapis, Kostopanagiotou, and Papagelopoulos (2009), an invasion of the origin of the gluteus maximus, gluteus medius, and piriformis muscles leads to local pain and subsequently decreases hip extension, abduction, and external rotation power. This clinical presentation described above is the clinical presentation shown in this case as the patient demonstrates an antalgic gait and may not be able to walk due to pain in extension during ambulation. As nerve roots become increasingly compressed by the tumor, a multiradicular sensory deficit develops including radicular pain radiating uni- or bilaterally into buttocks, posterior thigh or leg, and external genitalia (Mavrogenis, Patapis, Kostopanagiotou, & Papagelopoulos, 2009). Again, these clinical findings are showing up throughout the entirety of this patient’s history. Mavrogenis, Patapis, Kostopanagiotou, and Papagelopoulos (2009), also stated that a unilateral lesion to the S2 or S3 nerve root usually leads to mild or moderate bladder, bowel, and/or sexual dysfunction. A bilateral lesion of the S2 or S3 nerve root always results in complete bladder, bowel, and sexual dysfunction. To refer back to the portion of the case where the patient reported decreased sensation and sharp/dull on the heal and sole of the right foot lines up with a unilateral tumor of the sacrum that is large enough to be pushing on spinal nerve roots S1/S2 which peripheral nerve sensation of the medial calcaneal branches of the tibial nerve supplies the heal and medial surface of the sole of the foot. In accordance to all of the previous mentioned signs and symptoms described by Mavrogenis and colleagues, I believe this is one of my most top choices in regards to diagnosis.
What type of imaging can be done to detect a sacral tumor?
• To detect a sacral tumor, it is very difficult to strictly evaluate using a radiograph because it is often obscured by overlying stool or bowel gas.
According to Mavrogenis, Patapis, Kostopanagiotou, and Papagelopoulos (2009), conventional radiograph has a limited sensitivity and is only significant when it is abnormal showing the degree of osteolysis and sclerosis, and gross calcification or ossification within bone or adjacent soft tissue, or a pelvic mass. The presence of these signs requires further imaging evaluation by bone scintigraphy, computed tomography (CT) scan, or magnetic resonance imaging (MRI) (Mavrogenis, Patapis, Kostopanagiotou, & Papagelopoulos,
2009).
What are the conclusions from this patient presentation?
• Since I have been trying to treat this patient for 4 weeks and her pain has not improved, I am not going to continue treatment. Since she has gotten worse from the current treatment tells me is it not anything I am going to help and in fact, treatment is making it worse. I am fairly confident it is some type of cancerous tumor of the sacrum or a region nearby in which I would refer her to her primary care practioner without any further physical therapy treatment.
• When I first read about Carla’s presentation into the clinic, it sounded like it was piriformis syndrome. Although rarely recognized, piriformis syndrome appears to be a common cause of buttock and leg pain as a result of injury to the piriformis muscle. Symptoms are aggravated by prolonged hip flexion, adduction, and internal rotation, in the absence of low back or hip findings (Barton, 1991). Tonley et al. (2010) stated piriformis syndrome often evolves as intermittent and inconsistent and can present symptoms off and on throughout prolonged periods of time. Patients often report pain is insidious and deny any trauma that contributed to current symptoms. Patients also often state prolonged history of deep right buttock pain that radiates to the posterior thigh when piriformis syndrome is present (Tonley et al., 2010).
• Passive motion assessment of the hip joint in patients with piriformis syndrome often reveals normal ranges of motion for hip flexion, internal rotation, and external rotation without reproduction of symptoms (Tonley et al., 2010). Manual muscle testing above revealed slight weakness in the hamstrings which may be related to lower-crossed syndrome (LCS). In LCS, tightness of the thoracolumbar extensors on the …show more content…
dorsal side appears along with contralateral tightness of the iliopsoas and/or rectus femoris on the ventral side (making the first part of the “X or crossing of muscular tightness”), causing potential anterior rotation of the pelvis (Page, Frank, & Larnder, 2010). To expand upon this, at stated by Tonley et al. (2010), a common assumption guiding physical therapy intervention for piriformis syndrome is that the piriformis is shortened or in spasm, creating compression of the sciatic nerve. However, there is an alternate theory in which the piriformis muscle may be functioning in an elongated position or subjected to high eccentric loads during functional activities secondary to weak agonist muscles and the adopted anterior rotation of the pelvis also causing hamstring weakness as it is potentially elongated (Tonley et al., 2010; George, 2011). However, sciatic pain symptoms can be remarkably similar no matter what the source of pain truly is. Usually, there is some degree of actual pain in the buttocks, legs, or feet and can be cancer related (“Sciatica from Cancer,” 2015). Patients with cancer can endure all of the usual causes of sciatica, including spinal and nonspinal structural explanations. Sometimes, the tumor grows directly on a nerve structure (“Sciatica from Cancer,” 2015).
What is a spinal MRI going to look for and what will show up on this imaging?
• Magnetic Resonance Imaging was developed in the 1980’s and has revolutionized the ability to see normal and abnormal spinal structures and help diagnose back pain and possible disruptions in disc lesions, spinal cord compression, and many other possible diagnosis (Shalen, 2012). MRIs represent a very sensitive and accurate assessment of spinal anatomy, it cannot however distinguish between painful and non-painful structures in the spine. In fact, a patient may have severe back pain and an MRI that shows a relatively normal-looking spine, or conversely may have no back pain but the MRI reveals a lot of anatomical problems. Thus, the findings on MRI scans do not constitute a diagnosis (Shalen, 2012). MRIs can reveal spinal alignment, disc height and hydration, vertebral body configuration, intervertebral disc (normal, bulging, herniated, dehydrated, or degenerated), spinal canal size, nerves, abnormalities, and spinal cord appearance (Shalen, 2012).
Why was there a decrease sensation to light touch and sharp/dull?
• Sensation to touch and light/dull in the corresponding areas the patient presented with indicated either an S1 nerve root problem or potential peripheral nerve entrapment/compression (tibial nerve with medial and lateral plantar nerve distribution to medial/lateral portions of the foot respectively). Since this patient complained of low back pain/posterior hip pain on the right, and pain radiating down the posterolateral aspect of her leg and heel that was exacerbated on the straight leg raise, sounds like a potential sciatic nerve problem or disc involvement. However, what we don’t know from the description of this case is at what angle during the straight leg raise these symptoms came on. Was it at 0-35o where the sciatic nerve is slack and is taken up during the entirety of that range with no dural movement? Or was it during 35-70o of the range where the sciatic roots tense over the intravertebral disc during this range? Then if it is over 70o the sciatic nerve is no longer stretched and pain would indicate joint involvement (learned throughout experience in physical therapy program). Further information about this would be nice to know, however, it may still sound like there is more than one problem here because she has increased pain with palpation in the gluteal region which makes sense, however, she has it on anterior palpation just below her ASIS, which sounds like possible bone involvement such as a type of bone cancer or something other than a musculoskeletal problem.
Why is Indocin prescribed/what is it used for? What are some common side effects from taking Indocin?
• Indocin is a nonsteroidal anti-inflammatory drug (NSAID). Indocin (indomethacin) works by reducing hormones that cause inflammation and pain in the body (“Drugs”, 2016). Indomethacin is used to treat moderate to severe osteoarthritis, rheumatoid arthritis, gouty arthritis, or ankylosing spondylitis. It is also used to treat shoulder pain caused by bursitis or tendonitis. Indomethacin can increase your risk of fatal heart attack or stroke, especially if long term use or taking high doses, or if you have heart disease. This may also cause stomach or intestinal bleeding, which can be fatal (“Drugs”, 2016). This case has not given any specifics up until this point as to why the patient is taking Indocin, however, based on the information up until this point, it would make the most sense that this patient is taking this medication for anti-inflammatory purposes to reduce the cause of inflammation and pain the body she is experiencing.
What is the most logical reason for bladder urgency in this patient?
• This patient also indicated that over the past 2 years, she has experienced increased bladder urgency for which she has not sought medical attention. She also was diagnosed with irritable bowel syndrome about 10 months ago. Upon further research, it appears that bladder symptoms and irritable bowel syndrome (IBS) actually have a surprising overlap and that some researchers have estimated that urinary symptoms may be experienced as many as 50 percent of people who have IBS (Bolen, 2016). These symptoms include: frequent urination, incomplete emptying of the bladder, nocturia, urinary urgency. If this patient is indeed having pelvic pain which may seem like back pain, there are multiple organ systems in the pelvis, there is the gastrointestinal system (intestines), gynecologic system (ovaries and uterus), genitourinary system (bladder and kidneys) and all these three systems exist side by side in the pelvis so if pelvic pain, it can be one of the three (Bolen, 2016). The most common comes from gas and can be quick/sharp pain. However, this is a persistent pain or comes on and off (cyclic), it may be one of these systems above and should be screened (Bolen, 2016). The problem could also be Interstitial cystitis (IC), also known as painful bladder syndrome, on the surface looks like the urological counterpart of irritable bowel syndrome (IBS) (Bolen, 2016). Following the clinical presentations given in the case study, I do not think the patient has any of the following diagnoses that I have addressed in this objective; however, it was relevant information to consider given her history.
What are some additional differential diagnoses?
• Upon further research about Irritable Bowel Syndrome, I came across colorectal cancer. I found that colorectal cancer might not cause symptoms right away, but if it does, it may cause a change in bowel habits, such as diarrhea, constipation, or narrowing of the stool, that lasts for more than a few days which may be related to her bowel/bladder urgency (American Cancer Society, 2015). It may also lead to cramping or abdominal pain, weakness/fatigue, and unintended weight loss. This type of cancer can often bleed into the digestive tract. One thing we don’t know about in this case is if her stool looks normal. Over time, the blood loss can build up and can lead to low red blood cell counts (anemia) (American Cancer Society, 2015). A great thing to know in this case is what her numbers on a blood test look like and if her red blood cell count is low. This is one thing that I would really want to see. However, in early stages of the disease, colorectal cancer symptoms may be minimal, or not present at all. As the disease progresses, symptoms may increase in quantity and degree of severity. Because colorectal cancer symptoms often do not present themselves until the disease has progressed past the initial stage, regular screening is often recommended, and should be part of a continued health plan for anyone over 50 (Fisher & Daniels, 2014). It is not clear if this patient has a family history of colorectal cancer because if so, it is recommended that if you are under 50, which this patient is, individuals should talk with their doctor about when screening regularly should begin (Fisher & Daniels, 2014).
• Another interesting point is that colorectal cancer is broken down into two general categories: local and systemic. Local symptoms are those that have a direct effect on the colon or rectum. If symptoms are experienced for an extended period of time, it is important that a healthcare professional is contacted. The symptoms of a local colorectal cancer are more of the symptoms described previously. Systemic colorectal cancer symptoms are those that affect the entire body. If these symptoms are experienced for any lengths of time, or even a couple of days it is important that a healthcare professional is contacted. This would include unexplained weight loss, unexplained loss of appetite, nausea or vomiting, anemia, jaundice, weakness or fatigue (American Cancer Society, 2015). None of these are mentioned in this case study other than weakness/fatigue.
Could any type of neurological or autoimmune disease cause these types of clinical presentations?
• This patient also fits the presentation for multiple sclerosis (MS), although I do not think this is the patient’s current diagnosis. These individuals tend to have their first symptoms between ages 20 and 40 (Wootla, Eriguchi, & Rodriquez, 2012). The patient in this case is 35 years old and matches this description. Also, with MS, symptoms tend to get better, but then come back. Some symptoms may come and go, while others linger. This again, is another common theme we are seeing with this patient as she sometimes goes a few weeks without pain, and then the pain comes back. An important early symptom of MS to note is clumsiness or lack of coordination which is something we may be seeing from this patient as she has no limitations in ROM, not many limitations as far as weakness, however, demonstrates an antalgic gait pattern along with the inability to ambulate without crutches.
Could the cause of the patient’s current symptoms be present due to some type of cancerous or precancerous tumor?
• Tumors involving the sacrum could also be a more likely cause of this patient’s presentation as this type of problem can compress or invade neighboring structures (Mavrogenis, Patapis, Kostopanagiotou, & Papagelopoulos, 2009). Sacral tumors remain silent for a long time and the most common initial symptom of a sacral tumor is local pain due to its mass effect and compression. Occasionally, such as this case, lower sacral tumors can grow large enough for their anterior portion to be palpated during an examination. Lateral extension of sacral tumors across the sacroiliac joints cause local pain at the joint. According to Mavrogenis, Patapis, Kostopanagiotou, and Papagelopoulos (2009), an invasion of the origin of the gluteus maximus, gluteus medius, and piriformis muscles leads to local pain and subsequently decreases hip extension, abduction, and external rotation power. This clinical presentation described above is the clinical presentation shown in this case as the patient demonstrates an antalgic gait and may not be able to walk due to pain in extension during ambulation. As nerve roots become increasingly compressed by the tumor, a multiradicular sensory deficit develops including radicular pain radiating uni- or bilaterally into buttocks, posterior thigh or leg, and external genitalia (Mavrogenis, Patapis, Kostopanagiotou, & Papagelopoulos, 2009). Again, these clinical findings are showing up throughout the entirety of this patient’s history. Mavrogenis, Patapis, Kostopanagiotou, and Papagelopoulos (2009), also stated that a unilateral lesion to the S2 or S3 nerve root usually leads to mild or moderate bladder, bowel, and/or sexual dysfunction. A bilateral lesion of the S2 or S3 nerve root always results in complete bladder, bowel, and sexual dysfunction. To refer back to the portion of the case where the patient reported decreased sensation and sharp/dull on the heal and sole of the right foot lines up with a unilateral tumor of the sacrum that is large enough to be pushing on spinal nerve roots S1/S2 which peripheral nerve sensation of the medial calcaneal branches of the tibial nerve supplies the heal and medial surface of the sole of the foot. In accordance to all of the previous mentioned signs and symptoms described by Mavrogenis and colleagues, I believe this is one of my most top choices in regards to diagnosis.
What type of imaging can be done to detect a sacral tumor?
• To detect a sacral tumor, it is very difficult to strictly evaluate using a radiograph because it is often obscured by overlying stool or bowel gas.
According to Mavrogenis, Patapis, Kostopanagiotou, and Papagelopoulos (2009), conventional radiograph has a limited sensitivity and is only significant when it is abnormal showing the degree of osteolysis and sclerosis, and gross calcification or ossification within bone or adjacent soft tissue, or a pelvic mass. The presence of these signs requires further imaging evaluation by bone scintigraphy, computed tomography (CT) scan, or magnetic resonance imaging (MRI) (Mavrogenis, Patapis, Kostopanagiotou, & Papagelopoulos,
2009).
What are the conclusions from this patient presentation?
• Since I have been trying to treat this patient for 4 weeks and her pain has not improved, I am not going to continue treatment. Since she has gotten worse from the current treatment tells me is it not anything I am going to help and in fact, treatment is making it worse. I am fairly confident it is some type of cancerous tumor of the sacrum or a region nearby in which I would refer her to her primary care practioner without any further physical therapy treatment.